The United States has entered a new period of the coronavirus disease (COVID-19) pandemic that brings its own unique challenges. Some states are maintaining restrictions, but many are initiating plans to reopen or have already reopened, despite the continued upward trajectory of infections and deaths. While this may be interpreted as a positive sign for businesses, including dermatology practices, as profits may return sooner than expected, it is too early to say for certain that the worst is behind us. Whether level-headed local and state governments decide to initiate another shutdown if infection rates start to soar and the health care system is overwhelmed again is uncertain.
Uncertainty is the word that will capture this period in history for many, as the number of unknowns outweigh everything else. We are only starting to grasp how long the virus lives outside the body, how quickly it spreads, how it affects everything from the mucosa and lungs to the skin and heart, with still no clear evidence on treatment and vaccine efficacy as of yet.
In addition to these uncertainties, disruptions to everyday life add another layer of stresses, whether it is learning to adapt to working from home and homeschooling or the sudden loss of income. Everyone is confronted with similar roadblocks that add to the unique burdens with which we are already living. The state of burnout in the medical field, only beginning to be addressed within the last decade, will certainly not decline during a pandemic. In fact, a recent study showed rates of burnout were higher during the pandemic than previously reported rates.1
Stresses on mental health among dermatologists can only be expected to continue. Loss of income’ furloughing workers; learning a new telehealth platform if not already in place, counseling worried patients, some of whom may call more often as their support system is strangled; extra paper work for billing; and extra phone calls to request a hydroxychloroquine prescription due to current shortages are some of the new challenges dermatologists are facing.
In the midst of an infectious disease pandemic is a growing mental health crisis that is only starting to surface.2 One medical center in California reported seeing an increase in suicides,3 and an article published in JAMA Psychiatry discussed how social distancing measures and economic stress of the pandemic may increase suicide risk.4 Additionally, studies have shown health care workers have an increased risk for posttraumatic stress disorder and suicide ideation during large scale natural disasters and pandemics.5
Loss of loved ones, of normalcy, is difficult to handle even in the best of times. Now, we are all suffering through a pandemic that has stripped everyone of everything—travel, social interactions, trips to the mall—and this loss is felt individually, nationally, and globally. We can take some solace that we are not alone. The world we return to will be different.
In an interview for The Dermatologist, Richard Fried, MD, board-certified dermatologist and clinical psychologist based in Yardley, PA, spoke with me about how dermatologists can care for their mental health during the COVID-19 pandemic. While I would love to say this article is going to offer you a perfect recipe to help you deal with the anxieties, depression, and stress of living in the midst of a pandemic, I cannot make that promise. I do hope these tips at least help you reframe how you see the pandemic, remind you that even in the darkest times there can be joy, and offer you some hope that we will rise again from the ashes, as humanity has after plagues over the past hundreds of thousands of years.
Destruction of Normalcy
I do not think it is a stretch to say that most health care professionals, even in dermatology, view themselves separately from their patients. There is a clear “us” and “them” divide that comes with years of mastering a particular subject matter, and this creates an imaginary wall between physicians and the rest of the world, as well as a belief that this knowledge offers some form of protection.
“The pandemic was unique in that it quickly disrupted what we perceive as normalcy and permeated so many levels of perceived safety and protection,” said Dr Fried. The imaginary wall that separate physicians from patients was suddenly gone as reports from Italy, China, and other endemic regions showed a large percentage of nurses and doctors who contracted the disease and some who died while working on the frontlines due to lack of personal protective equipment (PPE), or even despite of PPE.6-9 No one was 100% safe from the virus, and the sense of imminent danger and possible death was heightened by the lack of PPE and equipment for the influx of patients, especially among those on the front lines and ones who are in constant contact with people.
“It is almost as if someone gave a sucker punch to the solar plexus,” said Dr Fried. Suddenly, physicians all across health care had to make decisions about their practices, even before state and local governments started lockdowns. “We had to make decisions about our own risks for going to work, and whether we are putting our patients, staff, and even our family and friends at risk,” he added. Most US practices shut their doors to everything but emergent or urgent cases, implemented telehealth platforms, and created schedules to stagger patients and staff to minimize the risk of infection.
A sense of safety in public may not return for many, as several states struggle to balance reopening safely with economic needs. Furthermore, many people for various reasons are not following best practices for preventing exposure.
Loss of Control
In addition to a loss of the imaginary wall is the loss of control that defines modern medicine. Physicians sell control, pharmaceutical companies definitely sell control, and the entire basis of medicine is about control of diseases, especially when eradication is not a viable option at the given time, explained Dr Fried. Suddenly, an airborne infectious disease surfaces and spreads throughout the entire world over a few months and many in the medical community were no longer able to maintain a sense of control. Some countries, such as New Zealand, have effectively managed to quell the spread of the virus.10 In the United States, responses have been slow, important measures for containing the spread were inconsistently implemented, and local and national government officials have largely ignored the advice of medical groups and public health experts.
According to Dr Fried, emotions that accompany the loss of control include anger, irritability, restlessness, agitation, obsession, preoccupation, and fatigue. These emotions are valid but also debilitating, because it can be hard to see an outside from them and they are easily fueled by the current climate of uncertainty and helplessness.
Sitting With Negativity
Before moving on to how we can think positively, I want to begin with talking about negative emotions as a reminder that sometimes it is okay to sit in our own darkness. The struggles we are facing as a person, family, city, nation, and world are all real, and they do not outweigh or compete with each other. In addition, we all experience these events and process our emotions in our own way. The pandemic has become particularly more isolating for people who have lost a loved one, and it can be hard to grieve other types of losses as well.
Living after loss is difficult. You may have known someone who died from COVID-19 or another cause but was unable to be given a traditional memorial or funeral. You may have lost your job, house, business, or you may be living in constant fear that you could be the next to be furloughed or file for unemployment. You may have lost your social connections with people because you are unable to attend places of worship or participate in gatherings, like book clubs, conferences, and family barbeques. My hometown has already cancelled its usual Fourth of July celebrations. When we lose something, it is normal to feel angry, sad, fear, and wallow in self-pity or anxiety. “These feelings are legitimate,” confirmed Dr Fried. “Sometimes, we need to be with our own negative emotions and that is ok,” he added.
“I have said to people ‘let’s remember our design is one that is to protect us from danger and damage,’” he said. For instance, when someone cares for a loved one who is very ill, which is upsetting, exhausting, and anxiety provoking, it is common for that person to want it to all go away and for the situation to end. “This can bring some very scary thoughts and impulses, which can include anything from a fleeting wish, such as wanting the person die, or long and thought out intrusive fantasies,” said Dr Fried. During this time, any thought or impulse is fair game, and it is normal for us to want something that jeopardizes us and our perceived sense of immortality destroyed. It is important we are careful and do not see ourselves and believe any of our thoughts or feelings are evil or wrong, because this is part of the human experience, according to Dr Fried. For example, a current and likely common momentary wish would be that the virus would get it over with and kill as many people as it needs to so we can return to normal.
While we cannot stress the importance of acknowledging the negative emotions you feel and will continue to feel through reopening, it is important to also know when to put an end to the thoughts and move on. Sitting with negative emotions can quickly becoming drowning if there is not a limit.
Moving Away and Looking Forward
There are several ways to reframe perception and shift from drowning in negativity towards more positive spaces. While a positive mindset is ideal, finding neutral ground and using it as a stepping stone may help those of us who struggle to get away from negative emotions that can fuel anxiety.
Dr Fried highlighted 2 methods of both behaving and thinking in order to shift away from catastrophizing:
- Being the good parent/role model
- “What if…/Well then…”
Being a Good Parent/Role Model
According to Dr Fried, a good parent is someone who helps a child frame, understand, and deal with the difficulties of life. In this scenario, the “child” can be yourself, a patient, family member, etc. One example of reframing the pandemic is by putting it into perspective historically. While this is a new virus, pandemics are not new and in fact we have lived through several outbreaks and pandemics in the last 20 years: MERS, SARS-CoV-1, H1N1, Zika virus, Ebola, and a resurgence in measles.
We are all frustrated and wondering how long it will take before the COVID-19 pandemic ends, but “it will take as long as it takes,” added Dr Fried. Many factors will influence the restoration of a true sense of normalcy. Studies reported that lockdown measures had a large effect in reducing transmission of the virus.11,12 As of June 15, 2020, the US has had 2,096,902 confirmed cases and 115,827 deaths.13 Despite the rising number of cases, states are reopening and concerns about a second wave are already looming. However, that wave too will pass.
Being the good parent is reframing so the weight of the moment does not eclipse the future and being a good role model is using positive language, ways of speaking, and engaging in positive activities so you and those around you are not trapped in an endless cycle of wallowing. This can be very difficult. Dr Fried recommended the following as ways to reframe and engage with positivity during this time:
- Establish and maintain a routine (eg, get out of bed, brush your teeth and shower, etc);
- Plan something to look forward to in a day, week, month, etc;
- Focus on the positive things in your life, even if it is acknowledging you are still healthy, have access to food and shelter, etc;
- Find a purpose and sense of control;
- Make a to-do list that includes emotional and social tasks;
- Connect meaningfully with family and friends (virtually, if necessary), such as spending more time with your children;
- Get into and follow an exercise routine;
- Learn about/practice mindfulness meditation; and
- Speak with a life coach or therapist.
The list can go on, but the main focus is “to rise to the occasion of functioning in spite of,” said Dr Fried. We are allowed to enjoy ourselves and experience positive feelings, such as happiness, during times of social distress. “We have to get up with a purpose and figure out what we can do that will make us feel as though we have a sense of control,” he stated. Otherwise, it is easy to fall into negative emotional states. One step is to do activities you associate with positive emotional states, such as learning a new language, “Marie-Kondo”-ing your home, finding a new hobby or restarting an old one, or watching a TV show you have been wanting to see.
For anyone who has not done so already, now may be a good time to take stock of one’s personal and professional lives. “What do you want to do and how do you want to change when things return to normal?” asked Dr Fried. Closing practices is stressful, but it does give physicians and other health care workers an opportunity to consider whether returning to the office is what they would like to do when the doors reopen. In a fast-paced environment, it is easy to get immersed in the day-to-day routine that some can go years without realizing they are unhappy with the direction of their professional or personal lives. Taking the time to reflect on and reprioritize aspects of your life, such as spending more time at home instead of in the office or vice versa, is important now and in the future as we return to a new normal.
It may be hard to see now and easy to forget, but there are some positive things coming out of the COVID-19 pandemic. Taking some time to look at the good that may come from this disruption can help reframe your thoughts. For example, “we are watching in real time how the scientific and medical community are taking data on something that appeared almost out of the blue, navigating uncharted territory, and mobilizing this information,” said Dr Fried. The number of discoveries made about the coronavirus disease and offending virus, SARS-CoV-2, is incredible, even in the midst of retracted papers and devastating morbidity and mortality. Within a short amount of time, the genome of the virus has been documented, several vaccines are in development and undergoing trials, and the sudden, almost overnight, embrace of telemedicine has shown how quickly the medical and scientific community are able to rally.
“What If…/Well Then…”
Catastrophizing, or the series of “what ifs” that plague our minds during this time, can take up a lot of mental space and take a toll on our ability to be a good parent or role model for ourselves and others. These thoughts can include:
- What if I (or my family member) gets COVID-19?
- What if I am (or my family member is) hospitalized?
- What if there is a second wave?
“When we begin to catastrophize, we have to speak in a very measured way,” said Dr Fried. He recommends following every “what if” scenario with a “well then.” In his practice, he uses this strategy to counsel his patients with melanoma in situ. “While melanoma in situ is 99% curable, anyone who has experienced something that could potential harm them, either in the short or long term, will every now and then have a little voice that says, ‘what if,’” he said. With melanoma, the answers to the what ifs, such as “what if it returns?” or “what if it spreads?”, is “well then, we remove it again” or “well then, we look at some of the immunomodulating inhibitors that treat melanoma.” The same approach can be used with COVID-19:
- What if I (or a family member) gets COVID-19? Well then, there is a 95% to 99% chance it will be a mild case and I just need to isolate and take care of myself/loved one.
- What if I am (or a family member) is hospitalized? Well then, there are some emerging options for medications.
- What if there is a second wave? Well then, we have records showing what public health measures work and are better equipped to handle it because we know more now than when the virus first appeared.
The main goal here is to turn attention away from the dread and anxiety caused by the “what ifs”–to not throw more fuel on the fire regardless of how tempting it is—and focus on something else that either creates positive emotions or at least neutralizes the anxiety.